Public-private collaboration in clinical research during pregnancy, lactation, and childhood: joint position statement of the Early Nutrition Academy and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Cross-sectional examination of commercial milk formula industry funding of international, regional and national healthcare professional associations: protocol

INTRODUCTION

Commercial milk formula manufacturers often emphasise their role in supporting infant and young child nutrition and breastfeeding, but their commercial goals to increase volume and profit margin of formula sales conflict with these declarations. Healthcare professional associations have an important role in healthcare worker education, shaping clinical practice. When healthcare professional associations enter into financial relationships with formula manufacturers, conflicts of interest arise, which may undermine education and practice that promotes optimal infant and young child feeding. The World Health Assembly calls on all parties to avoid such conflicts of interest, but it is uncertain how often this recommendation is followed. This protocol documents a systematic method to identify funding from the commercial milk formula industry among international, regional and national associations of healthcare professionals.

METHODS AND ANALYSIS

Using systematic search strategies in the Gale Directory Library and Google, we will identify international healthcare professional associations relevant to maternal and child health. Data regarding funding relationships with the commercial milk formula industry over the past 24 months will be extracted from the official websites or, in their absence, social media accounts by two independent analysts. The analysis will focus on the presence of conflict of interest or sponsorship policies and type of funding, such as sponsorship or payment for services.

ETHICS AND DISSEMINATION

This study does not require ethical approval and will use data available in the public domain. The results will be disseminated through peer-reviewed journal articles, at conferences and among the healthcare professional associations.

Promoting Breastfeeding and Interaction of Pediatric Associations With Providers of Nutritional Products

Pediatric associations have been urged not to interact with and not to accept support from commercial providers of breast milk substitutes (BMSs), based on the assumption that such interaction would lead to diminished promotion and support of breastfeeding. The leadership of seven European pediatric learned societies reviewed the issue and share their position and policy conclusions here. We consider breastfeeding as the best way of infant feeding and strongly encourage its active promotion, protection, and support. We support the World Health Organization (WHO) Code of Marketing of BMSs. Infant formula and follow-on formula for older infants should not be advertised to families or the public, to avoid undermining breastfeeding. With consistently restricted marketing of BMSs, families need counseling on infant feeding choices by well-informed pediatricians. Current and trustworthy information is shared through congresses and other medical education directed and supervised by independent pediatric organizations or public bodies. Financial support from commercial organizations for congresses, educational, and scientific activities of pediatric organizations is an acceptable option if scientific, ethical, societal, and legal standards are followed; any influence of commercial organizations on the program is excluded, and transparency is ensured. Public-private research collaborations for improving and evaluating pharmaceuticals, vaccines, medical devices, dietetic products, and other products and services for children are actively encouraged, provided they are guided by the goal of enhancing child health and are performed following established high standards. We support increasing investment of public funding for research aiming at promoting child health, as well as for medical education.

Managing Conflicts and Maximizing Transparency in Industry-Funded Research

BACKGROUND

Industry funding of research comes with important conflicts of interest, especially when research findings have financial implications for funders. When considering industry funding, academic investigators seek ways to mitigate and manage conflict to ensure integrity of research design, analysis, interpretation, and to protect researchers' and their institutions' credibility. This qualitative study's purpose was to conduct semi-structured interviews with expert stakeholders to gain insight into industry funding of research focused on nutrition and obesity, and determine the feasibility of developing a transparent process using an advisory board to help govern industry funding and manage conflict.

METHODS

We conducted seven semi-structured interviews with a purposive group of expert stakeholders representing varied perspectives. We distributed a summary of the advisory board concept to interviewees; developed and used a 16-question interview guide; and analyzed the interviews using open coding, manifest content analysis, axial coding, and code list reviews to identify and refine themes.

RESULTS

Most interviewees agreed that managing conflicts between industry funders and researchers was possible but difficult. They believed a carefully constructed advisory board empowered with specific responsibilities could help facilitate this process. They posited that strict guidelines are required to protect research quality and reporting, researcher(s)' and research institution(s)' reputations, and subsequent policy influenced by the research findings. They recommended specific guidelines and a framework for developing and administering the advisory board.

CONCLUSIONS

A carefully constructed advisory board empowered with specific responsibilities could be useful to manage actual and perceived conflicts of interest, and increase transparency of research processes, funding, and results for industry-funded research. Stricter guidelines than those previously proposed in existing frameworks are needed to instill confidence in industry-funded nutrition and obesity research. A possible next step could include a pilot study of the advisory board concept to determine specific requirements for execution and to develop rigorous guidelines.

The LifeCycle Project-EU Child Cohort Network: a federated analysis infrastructure and harmonized data of more than 250,000 children and parents

Early life is an important window of opportunity to improve health across the full lifecycle. An accumulating body of evidence suggests that exposure to adverse stressors during early life leads to developmental adaptations, which subsequently affect disease risk in later life. Also, geographical, socio-economic, and ethnic differences are related to health inequalities from early life onwards. To address these important public health challenges, many European pregnancy and childhood cohorts have been established over the last 30 years. The enormous wealth of data of these cohorts has led to important new biological insights and important impact for health from early life onwards. The impact of these cohorts and their data could be further increased by combining data from different cohorts. Combining data will lead to the possibility of identifying smaller effect estimates, and the opportunity to better identify risk groups and risk factors leading to disease across the lifecycle across countries. Also, it enables research on better causal understanding and modelling of life course health trajectories. The EU Child Cohort Network, established by the Horizon2020-funded LifeCycle Project, brings together nineteen pregnancy and childhood cohorts, together including more than 250,000 children and their parents. A large set of variables has been harmonised and standardized across these cohorts. The harmonized data are kept within each institution and can be accessed by external researchers through a shared federated data analysis platform using the R-based platform DataSHIELD, which takes relevant national and international data regulations into account. The EU Child Cohort Network has an open character. All protocols for data harmonization and setting up the data analysis platform are available online. The EU Child Cohort Network creates great opportunities for researchers to use data from different cohorts, during and beyond the LifeCycle Project duration. It also provides a novel model for collaborative research in large research infrastructures with individual-level data. The LifeCycle Project will translate results from research using the EU Child Cohort Network into recommendations for targeted prevention strategies to improve health trajectories for current and future generations by optimizing their earliest phases of life.

Role of Incentives in Long-term Nutritional and Growth Studies in Children

Available published advice on use of incentives is limited and generally refers to short-term studies without longer follow-up, predominantly conducted in developed countries. We aim to summarize published information related to the use of incentives in long-term nutrition studies involving infants, children, and adolescents and the views of researchers in the field, to provide guidance on acceptable incentives. We conducted a literature review and a short online survey of researchers regarding their opinions on the use of incentives in paediatric long-term (follow-up) clinical studies. Responses from 38 researchers from 14 different countries indicated that 41% had used incentives to increase participation and 29% to 73%, depending on child's age and type of procedure, thought incentives may be used to increase compliance with follow-up visits. A small number of respondents thought incentives would not be approved by national ethics boards. Based on the literature review and the survey results, and European Society for Paediatric Gastroenterology, Hepatology and Nutrition working group concluded that incentives for children and adolescents up to the value of 30 Euros, based on average EU income levels, may be offered as cash, vouchers, or age-appropriate gifts or toys, in addition to reimbursing expenses. Additional incentives may be offered if a study includes more burdening procedures, techniques that may appear frightening for younger children, or requires sustained participation (eg, dietary diaries or activity monitoring). There was agreement that it is preferable to give toys or gifts rather than money to younger children.

Ethical Challenges in Infant Feeding Research

Infants have a complex set of nutrient requirements to meet the demands of their high metabolic rate, growth, and immunological and cognitive development. Infant nutrition lays the foundation for health throughout life. While infant feeding research is essential, it must be conducted to the highest ethical standards. The objective of this paper is to discuss the implications of developments in infant nutrition for the ethics of infant feeding research and the implications for obtaining informed consent. A search was undertaken of the papers in the medical literature using the PubMed, Science Direct, Web of Knowledge, Proquest, and CINAHL databases. From a total of 9303 papers identified, the full text of 87 articles that contained discussion of issues in consent in infant feeding trials were obtained and read and after further screening 42 papers were included in the results and discussion. Recent developments in infant nutrition of significance to ethics assessment include the improved survival of low birth weight infants, increasing evidence of the value of breastfeeding and evidence of the lifelong importance of infant feeding and development in the first 1000 days of life in chronic disease epidemiology. Informed consent is a difficult issue, but should always include information on the value of preserving breastfeeding options. Project monitoring should be cognisant of the long term implications of growth rates and early life nutrition.

Regulation of early human growth: impact on long-term health

Growth and development are central characteristics of childhood. Deviations from normal growth can indicate serious health challenges. The adverse impact of early growth faltering and malnutrition on later health has long been known. In contrast, the impact of rapid early weight and body fat gain on programming of later disease risk have only recently received increased attention. Numerous observational studies related diet in early childhood and rapid early growth to the risk of later obesity and associated disorders. Causality was confirmed in a large, double-blind randomised trial testing the 'Early Protein Hypothesis'. In this trial we found that attenuation of protein supply in infancy normalized early growth and markedly reduced obesity prevalence in early school age. These results indicate the need to describe and analyse growth patterns and their regulation through diet in more detail and to characterize the underlying metabolic and epigenetic mechanisms, given the potential major relevance for public health and policy. Better understanding of growth patterns and their regulation could have major benefits for the promotion of public health, consumer-orientated nutrition recommendations, and the development of improved food products for specific target populations.

Clinical practice guidelines: based on eminence or evidence?

BACKGROUND

Too often, clinical practice guidelines, or similar documents, are of poor quality or are eminence based. Consequently, health care decisions might be based on biased or erroneous information. Here, issues related to standards for clinical practice guidelines that ensure the inclusion of objective, transparent, and scientifically valid information will be discussed.

KEY MESSAGES

To ensure the quality of guidelines, standards for the development of evidence-based clinical practice guidelines have been in development. While differences among them exist, overall, these documents emphasize the need for the establishment of transparency, management of conflicts of interest, use of a multidisciplinary development group, utilization of a systematic literature review, use of grading systems to rate the strength of evidence recommendations, articulation of recommendations, performance of an external review, and regular updating.

CONCLUSIONS

No clinical practice guidelines are perfect. They vary significantly in quality and, therefore, in the trustworthiness of the yielded recommendations. Hence, it is important that one can distinguish evidence-based clinical practice guidelines from guidelines that are not based on evidence. Standards for the development of evidence-based guidelines have been developed. If strictly adhered to, this should lead to more valid and trustworthy guidelines.

The Power of Programming and the EarlyNutrition project: opportunities for health promotion by nutrition during the first thousand days of life and beyond

At The Power of Programming 2014 Conference, researchers from multiple disciplines presented and discussed the effects of early nutrition and other environmental cues during the first thousand days of life and beyond on the lifelong risk of noncommunicable diseases. This paper aims to summarize the concepts and some of the first achievements of the EarlyNutrition research project that initiated the conference. The EarlyNutrition consortium is a multinational, multidisciplinary research collaboration of researchers from Europe, the USA, and Australia. A focus is placed on exploration of the developmental origins of obesity, adiposity, and related health outcomes. Here we report on the first findings of experimental approaches, cohort studies, randomized clinical trials, and systematic reviews of current information, as well as position papers, which have all been developed with the involvement of project partners. We conclude that the EarlyNutrition project has successfully established itself during the first 2 project years as a very strong platform for collaborative research on early programming effects. The first results, available already at this early stage of the project, point to great opportunities for health prevention strategies via the implementation of dietary and lifestyle modifications, with large effect sizes. Further results are expected which should support improved recommendations and related policies for optimized nutrition and lifestyle choices before and during pregnancy, in infancy, and in early childhood.